The following includes the Right to Payment (Assignment of Benefits), Patient Responsibility and Release of Information Form
447 Broadway 2nd FL #676
New York, NY 10016
I agree to irrevocably assign to the member(s) of the FaceMyDoc network rendering telemedicine services to me (“Provider(s)”), all of my rights and benefits and any other interests that I have in any medical insurance plan, health benefit plan, indemnity plan, trust, fund or other source of payment for healthcare services (each a “Plan”) in connection with medical services provided by Provider(s), its employees and agents. I understand that this document is a direct assignment of my rights and benefits under my Plan.
I instruct my insurance company to pay Provider(s) directly for the professional or medical expense benefits payable to me. If my current policy prohibits direct payment to Provider(s), I instruct my insurance company to make out the check to me and mail it directly to the address referenced above for the professional or medical expense benefits payable to me under my Plan as payment towards the total charges for the services rendered. In addition, I agree and understand that any funds I receive by my insurance company due for services rendered by Provider(s) will be immediately signed over and sent directly to Provider(s).
I acknowledge and agree that I am responsible for all charges for services provided to me which are not covered by my Plan or for which I am responsible for payment under my Plan. To the extent no coverage exists under my Plan, I acknowledge that I am responsible for all charges for services provided and agree to pay all charges not covered by my Plan.
Release of Information
I authorize Provider(s) and/or its agents to release any medical or other information about me in its possession to my Plan, the Social Security Administration, any state administrative agency, or their intermediaries or fiscal agents required or requested in connection with any claim for services rendered to me by Provider(s).
A photocopy of this Assignment shall be considered as effective and valid as the original.
Submission of the form this agreement is attached to shall have the same effect as affixing my signature hereto.